Single-Centre Experience With Low-Volume Plasma Exchange and Low-Dose Steroid to Treat Patients With Idiosyncratic Drug-Induced Acute Liver Failure

Abstract

BackgroundIdiosyncratic drug induced liver injury (iDILI) causing acute liver failure (ALF) carries high short-term mortality and patients who meet King’s College hospital criteria for liver transplantation have 1-month survival of 34% without liver transplantation (PMID: 20949552). We present our experience with low volume plasma exchange (PLEX-LV, 50% of estimated plasma volume exchanged per session) and low dose steroid to treat iDILI ALF. MethodsWe retrospectively analyzed data of patients with iDILI (diagnosed as per RUCAM score), treated with PLEX-LV and low dose steroid (Prednisolone: 10 mg OD, with rapid taper) in our department from 2016 to 2022. Baseline and dynamic parameters (post-PLEX) were assessed as predictors of 1-month liver transplantation free survival. ResultsTwenty-two iDILI patients [probable: possible iDILI: 20:2, males: 9, age: 30 (14-84) years, median (range); MELD score: 30.5 (19-43)] underwent PLEX-LV for ALF during the study period.Causative agents were complementary and alternative medications (36%), antiepileptics (18%) antimicrobials (14%), antitubercular drugs (14%), antifungal drugs(9%)and others (9%). All patients had jaundice and encephalopathy; 9 patients also had ascites. None of the patients underwent liver transplantation. Study patients underwent 3 (1-7) PLEX sessions and 1.4 (0.6-1.6) litres of plasma was exchanged per session.One-month transplant free survival was 59% (13/22) in the study population and 63% (12/19) among patients who fulfilled Kings College Hospital Criteria for liver transplantation. Reduction of ≥25% in plasma Von Willebrand factor (VWF) levels after PLEX-LV predicted improved survival (HR: 0.09, 95%CI: 0.01-0.65; AUROC: 0.81; 95% CI: 0.6-1.0). ConclusionLow volume PLEX and low dose steroid appears a promising treatment option in patients with iDILI induced ALF not opting for liver transplantation. Dynamic changes in VWF level after PLEX predict 1 month survival in these patients.